9 NORTHEY ST - BUILDING INSPECTION (3) EI1'�tOF g
PUBLIC PROPERTY
DEPARTbIF.,�iT
KI%RIEMEY DRISCOLL
MAYOR
12D WASMSaMN ST� I&I-Xy.MASLACKSM-i3 01970
T EL-976.74S.9S"*FAY:97&740.9"
APPLICATION FOR THE REPAIR. RENOVATION CONSTRUCTION
DEMOLITION OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTLF OR BUILDIN
1.0 SITE INFORMATION "
Location Name: Building:
Property Address:
P
dl-Ile u h,
Property Is located in a; Co atkln Area Y/N Historic Dlatrlot Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address: Z e•✓1 s• O 6�-eV D41 vt-'
�zu U s ss c9/ E06
Telephone: 7
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Additi Existing 12Sa
Renovation Number of Storie Ren
3�
Change in Use New
Demoli0on Existing
Approximate year of Area per floor (sf) Renovate 2Z�
construction or renovation �9 Al/
of existing building New
Elder Description of Proposed Work:
I'C/O d4L� /("�' � �69�
sryw�e We Aec foes
— Mail Permit to: --
i
What is the current use of the Building?
3
�a�r*4 a If dwelling,how many units
Material of Building?
Asbestos?
WIN the Building Conform 19 Law?
Arctided's Name 4
Address and Phone' S}22 h
Machanic's Name YI Ic
Address and Phone
�4 I
Construction Supervisors t i nse# 6�i t5 HIC Registration#
permit Fee Calculation
Estimated Cost of P�roles$1 Estimated Cost X$7/31000 Residential
panne Fee S r
Estimated Cost X 311/51000 Commercial
An Additional $6.00 is added as an
Administrative charge-
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the above stated
specifications. Signed under penalty of perjury
Date
� I
r N
s s G
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
tUMBERLEY DRISCOLL
MAYOR
120 WASHMTONSTREET•SA EM,MASSACHUSE171301970
TEWorkers' Compensation Insurance AiHdavit: Bullders/Contractors/E ectridans/Plumbers
Applicant Informatio
Please nt Le
Name(Business/organizadon/Individual): �if.`2 rye
Address:_
City/State/Zip: N-t JrA, c Phone #:_
Are you sn employer?Check the appropriate box:
1. I am a employer with 4. I am a general contractor and IWinfwmai
project(regttired):
2. }employees(full and/or past-time).• have hired the subcontractorsew construction
am a sole proprietor or partner_ listed on the attached sheet tg
Y ship and have no employees These sub-contractors have
working for me in any capacity, workers' co emolition
[No workers' camp. insurance 5. �' ti nrand i
P ❑ We are a corporation and its ilding addition
required.] officers have exercised their ectrical
3. I am a homeowner doing all work right of ex aoanPa+*s or additions
myself.[No workers'co �P Per MGL mbing repairs or addition
insurance required)t em loy ees. [ and we have no of repairs
P Y [No workers'
comp. insurance required] er
fH apomaow ca that cheeks box#1 must Was fill om the section below showing their
who submit this dRdavit i elicating they am doing all work and then him woekem pumcmrn policynamanam
tCoxetaetots that chat this box must atheked an a"tioml sheet showm out•ids tantractms must submit a ttew aR9dsvit.
mficating such,
g the Dame of Pon enb-conttactms and their workets•comp policy Wartelim
I am an employer that Lr providing workers'compensation lnsarance for my employees, Below Is the polky andJob sNe
information
Insurance Company Name:
Policy#or Self-ins.Lic.#:
Expiration Date:
Job Site Address:
A City/State/Zip:�-.
-Attach a copy ofdhe workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day aga the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the D r' cc coverage verification
I do hereby ca n er the pa nd penalties of perjury'hat the information provided above it true and correct
Si n
D oc a -3 �0�6
P
OJJiciai use only. Do not write in this area to be completed by city or town oJjiciaL
City or Town:
Issuing Authority(circle one): Permit/License#
I. Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector
6.Other
Contact Person•
Phone#•
Information and Instructions n for their employees
its General Laws chapter 152 requires all employers to provide workers compensation contiact of hire,
employees-
Massachusetts is defined as"...every person in the service of another under Y ' , f
Pursuant to this statute,an employee
express or implied,oral or written." two or more
is defined as"an individual,Partnership.association,c°rP°TBaon or other legal entity-or loY«'or
An employera joint enterprise.and including the legal representatives of a deceased employer-
of the foregoing engaged erprie,aassociation or other legal entity,employing employees. However the
tee of an individual.Partnership, antof the
receiver or iris house hav is not mom than three apartments and who resides therein,Or
dwelling house
owner of a dwelling who employs Persons to do maintenance+consottiction or repair to be an employer."
dwelling house of another thereto shall not because of such employment be deemed
or on the grounds or building appurtenant
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the thforissua a or
renewal of a license or Permit to operate a business or to construct buildings m the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance nor any of tspoliticalcoverage subdivisions shall
Additionally.MGI:chapter 152,§25CV)states"Neither the conunnowee et evidence of compliance with the insurance
enter into any contract for the performance of public work until steep
resented to the contracting authority"
requirements of this chapter have been p
Applicant checking the boxes that apply to your situation and,if
on affidavit completely,by number(s)along with then ccrtificate(s)of
Please fill out the workers' compensation ati c(s),addcess(es)and P with it employees other than the
necessary.supply sub-conm mP or Limited Liability Partnerships(LLP)
insurance. Limited Liability Companies(LLC) lion insurance. If an LLC or LLP dues have
armors,are not required to carry worker'compensation artm of Industrial
member or p Be advised that this affidavit may be submitted to the Dep
employees.a policy is required be sure to sign and date the at5davit. The affidavit should
Accidents for confirmation of insurance coverage. Also or license is being requested,not the Department
be returned to the city or town that the application for the Permitthe law or if you are required to obtain a worker'
industrial Accidents' Should you have any questions regarding companies should enter their
Please call the Departiaent at the number listed-below. Self:insured
compensation policy,p
self-insurance license munber on the a riate line.
City or Town Offleisis
that the affidavit is complete and printed legibly. The Department has Provided a space at the bottom
arding the a applicant.
Please be sure titan
of the affidavit for you to fill out
in the event
e number which will be used as a reference number. In addition,an PP
Please be sure to fill in the Pe dlicenss applications in any given year,need only submit one affidavit indicating current
that must submit multiple permi ..Job Site Address"the applicant should write"all locations in (city or
stamped
or marked by the city or town may be provided to the
policy information(if necessary) out_
town)."A copy of the affidavit that has been officially tamp be
applicant as proof that a valid affidavit is on file for fuiure permits t not elated to any busineiss o�catotnnerc�ial venue
Year.Where a home owner or citizen is obtaining a license or.Perini to complete this affidavit.
(i.e. a dog license or permit to burn leaves etc.)said person is NOT required tip
and should you have any questions,
The Office of investigations woulder to thank yo
u in advance for your cooperation
please do not hesitate to give
The Department's address,telephone and fax number.
The Commonwealth of Massachusetts
Depattment of Industrial Accidents
omee of Invesdptions_
600 Washington sheet
Boston MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www.nim.gov/dia
.. CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
,�eoaaar oaaoott.
NAroa 130 WAUGNU N STU=•SAN 9- MAMCHMM GIWM
1%U 9T US-""0 FA34 9M7ia96N
Constmedon Debris Disposal Affidavit
(required for all demolition and movstion wank)
In accordaeas with the sixt>t edition of"Sate Building Code.780 CUR section l 11.5
Debris]and the provisions of MQ.a A S S*
Building Peerrdt N is inn"with the condition flat the debris rnsuM*fiom
No work shall be disposed of in a propa<ly licensed waste disposal theility as defined by MOL e
1 L 1.3150A.
The debris will be transported by:
(aama ottttoytlsr)
The debris will be disposed of in:
(name o(t3eility)
I
(atdrm of faaitity)
:i of
1 L) a,T
i